Office of the Provost

Checklist Cover Sheet

Candidate’s Last Name_____________________________________

                                                            CHECKLIST COVER SHEET

This form is to be the first page of all nominations. All items must be attached and all certifications completed. Please photocopy this form as needed for submission of your nominations.

CANDIDATE'S FULL NAME: ___________________________________________________

CANDIDATE'S CAMPUS: _______________________________________________________

FULL POSITION TITLE: ________________________________________________________

DATE OF HIRE FOR THIS POSITION: ____________________________________________

CANDIDATE'S DEPARTMENT: _________________________________________________

CHECK THE PROGRAM TO WHICH THE NOMINATION IS BEING SUBMITTED

□   Excellence in Faculty Service

□   Excellence in Librarianship

□   Excellence in Professional Service

□   Excellence in Scholarship and Creative Activities

□   Excellence in Teaching

ENDORSEMENT OF CAMPUS PRESIDENT (REQUIRED)

I certify campus endorsement of this nomination and compliance with program requirements.

____________________________________________        __________________________

President's Signature                                                                              Date

___________________________________________

President's Telephone Number

MATERIALS SUBMITTED IN CONJUNCTION WITH THE NOMINATION

The documentation identified below is required as part of the nominee’s dossier. Please verify its inclusion in the nomination packet by checking the appropriate boxes.

□          President's Transmittal Letter                                  □    Summary Presentation

□          Description of Nomination Procedures                      □    Current Curriculum Vita

CAMPUS CONTACT

Please type the name and telephone number of the individual to be contacted in case questions regarding the nomination arise. The campus is to identify a single individual as the designated contact for all nominations submitted.

Name & Title ________________________________   Phone Number ____________________                                                                                              

CERTIFICATIONS

Please certify campus compliance with the Policies and Procedures by checking each of the certifications below. (Please do not include separate statements regarding the certifications.)

□   Local Selection Committee - This is to certify that the local selection committee was structured as directed and complied with the current Policies and Procedures.      

□   Eligibility Requirements - This is to certify that the nominee satisfies all eligibility criteria for the program as prescribed in the current Policies and Procedures. Note that an individual is only allowed to receive a Chancellor’s Award for Excellence once in five (5) years.

□   Compliance with Policies - This is to certify that this nomination complies with the current Policies and Procedures.

This form is also available online at: http://www.suny.edu/provost/academic_affairs/ChancellorsAwards.cfm

EXPLAIN BELOW ANY DEPARTURES FROM POLICY AS STATED IN THE CURRENT GUIDELINES.